Daniel Low, Ph.D. Director, Division of Medical Physics Radiation Oncology Washington University
Colleagues
Wei Lu Parag Parikh James Hubenschmidt Jeffrey Bradley Sasa Mutic Joe Repp Sasa Wahab Issam El Naqa Gary Christensen
Outline
Why is 4D CT necessary? What is 4D CT? How do we characterize breathing? What do we do with 4D CT information?
Outline
Why is 4D CT necessary? What is 4D CT? How do we characterize breathing? What do we do with 4D CT information?
Why is 4D CT Necessary?
Breathing
Quasi-voluntary function Breath hold possible Modification of breathing pattern possible
Motion
Image artifacts Dose-delivery artifacts Increases irradiated volume/treatment complexity
Treatment Effects
Breathing motion increases the apparent size of the tumor
Increases portal sizes Increases normal organ irradiation
Motion Blurring
Required Margin
Interplay Effects
Interplay: Fractionated
Fractionated therapy tends to blur dose errors Beam motion tends to be orthogonal to patient motion
Multiple simulations with realistic IMRT dose distributions Analyzed multiple points to determine dose error due to motion Results: Dose error depended on whether point was in/near steep dose gradient region, but dose was local average Bortfeld et al, PMB 2002
Outline
Why is 4D CT necessary? What is 4D CT? How do we characterize breathing What do we do with 4D CT information?
What is 4D CT?
Process for obtaining image datasets
Images used to determine tumor/normal organ motion Motion information used as inputs for treatment planning, delivery, verification
Metric - Spirometry
Turbine-shaped fan encased in tube Rotation rate determines flow rate Software removes nonlinearities and integrates flow
4D CT Process
Image acquisition
Cin or helical modes
Simultaneous monitoring of patient breathing
Helical mode
Easiest for commercial applications: uses cardiac gating software
Philips Bellows
Bronchial Branch 12-Slice mode Spirometry Tidal Volume Acquisition Spirometry Drift Correction
DICOM Transfer
Volume-Gated Images
Acquisition Process
Motion Model Parameter Determination
98 ml time 94 ml 90 ml
3D CT At 100 ml
volume
Gating
Have process that
Acquires CT images Sorts CT images using metric data
However
What criteria are used to determine the patients breathing phase associated with each image?
Inhalation Exhalation
Phase Angle
Breathing cycle described as purely periodic process Inhalation exhalation defined by angles from 0-360 degrees
Vedam et al, PMB 2003
Select mid-inspiration
Mid-inspiration defined by percentile tidal volumes
Phase
Mid-inspiration defined by time between exhalation and inhalation peaks Time (s)
Amplitude sorting
Phase sorting
Amplitude vs Phase
What 4D CT Can Do
Clinical Images
Difficulties with amplitude-based retrospective gating is that images are not necessarily acquired at the same breathing phase for each couch position Interpolation may be a method for interpolating to a common breathing phase Requires a deformable map of motion
Quality Assurance
Accuracy of 4D process Phantoms developed to QA process Some operate in 1D, periodic
Breathing is non-periodic Breathing motion is 3D
QA of 4D
Independent 3D Digitizer Motorized Stages
Example: Calypso
QA of 4D
What Next?
We have a method for describing breathing cycle We can create 3D image datasets at specific breathing phases What do we do with this info? A) Create 3D CT at specific phases
Contour these phases and use the data
Outline
Why is 4D CT necessary? What is 4D CT? How do we characterize breathing? What do we do with 4D CT information?
Seppenwoolde et al. Int. J. Radiation Oncology Biol. Phys., Vol. 53, No. 4, pp. 822834, 2002
Mathematical Model
Linear Approximation Breathing cycle is defined by Tidal Volume and Airflow Nonlinear motion comes from airflow f = dv/dt and shape of airflow curve
0.62 mm
0.70 mm
0.66 mm
Breathing
How do we define the breathing cycle? What is an inhalation and exhalation? How do the acquired images correspond to the actual tumor positions during treatment?
ITV creation requires accurate understanding of breathing cycle
Breathing Patterns
Breathing Patterns
Regular Breather
v85
v5
Irregular Breather
v85
v5
Images that cover 80% of breathing cycle show only 72% of the motion at 93% of the breathing cycle!
Outline
Why is 4D CT necessary? What is 4D CT? How do we characterize breathing? What do we do with 4D CT information?
Treatment Planning
Images provide Geometry (functional) data for treatment planning Treatment planning provides prediction of treatment course
Spatial uncertainties = margins Extrapolation
Breathing motion
ITV Gating Tracking
ITV
Gating
Spatial window
Determined by planning process via dosimetric considerations
Anteroposterior
Spatial Window
Probability Distribution
Craniocaudal
Tracking
Tracking system require very accurate understanding of tumor position When you track the tumor, you untrack everything else
Critical structures define dose limits, not tumors
Implants alone
Calypso Medical
Conclusions
More quantitation is required! Amplitude-based gating = ability to extrapolate from existing image data 4D CT should be used as data to feed a mathematical/physical model of human breathing The model feeds the treatment planning process